1366629594 NPI number — LAWRENCE B RUBIN DPM PC

Table of content: (NPI 1366629594)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366629594 NPI number — LAWRENCE B RUBIN DPM PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAWRENCE B RUBIN DPM PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366629594
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18530 GRAND RIVER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-273-9400
Provider Business Mailing Address Fax Number:
313-273-5612

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18530 GRAND RIVER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-273-9400
Provider Business Practice Location Address Fax Number:
313-273-5612
Provider Enumeration Date:
01/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
RUBIN
Authorized Official First Name:
LAWRENCE
Authorized Official Middle Name:
BLAKE
Authorized Official Title or Position:
PRESIDENT OWNER
Authorized Official Telephone Number:
313-273-9400

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  5901000839 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1391060 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com